3rd wrong-site neurosurg in 1 year, same hosp

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gasnewby

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i can see how this happens, especially in ortho, if the attending walks in and the patient's already prepped and draped, but come on!

Hospital Makes 3rd Brain Surgery Mistake

PROVIDENCE, R.I. (AP) -- Rhode Island Hospital has been fined $50,000 and reprimanded by the state Department of Health after its third instance this year of a doctor performing brain surgery in the wrong side of a patient's head.

"We are extremely concerned about this continuing pattern," health department director David R. Gifford said in a statement Monday.
The hospital issued a statement saying it was re-evaluating its training and policies, providing more oversight, giving nursing staff the power to ensure procedures are followed, among other steps.

The most recent case happened Friday when the chief resident started operating on the wrong side of an 82-year-old patient's brain, the health department said. The patient was OK, the health department and hospital said.

In February, a different doctor performed neurosurgery on the wrong side of another patient's head, said Andrea Bagnall-Degos, a health department spokeswoman. That patient was also OK, she said.

In August, however, a patient died a few weeks after a third doctor operated on the wrong side of his brain. The death prompted the state to order the hospital to take a series of steps to ensure such a mistake would not happen again, including an independent review of its neurosurgery practices and better verification from doctors of surgery plans.

The hospital is owned by Lifespan, a not-for-profit corporation. It serves as a teaching hospital for Brown University.
 
I wonder if they see the patient before going into the OR... lol
 
I wonder if the attending is there at all. 😎
 
Where I am the patient doesn't roll back from holding area until they have a Green Circle on their site of surgery. Then we have a timeout before the case starts to again verify everything including patient name. I guess this helps as I haven't heard of anything like this. RI needs some better better protocols in place to prevent this sort of mishap.
 
Where I am the patient doesn't roll back from holding area until they have a Green Circle on their site of surgery. Then we have a timeout before the case starts to again verify everything including patient name. I guess this helps as I haven't heard of anything like this. RI needs some better better protocols in place to prevent this sort of mishap.

There are many many ways to avoid this kind of error... It can happen to you in an regular inguinal hernia repair... :S (I've seen it happen)...

starting from the easy-ones to do:
examining your patient pre-op. (good one)
putting a not in the chart (and reading the chart)...
or making a landmark, signature, sign, color, sticker, or anything preop that will remind you that you are operating the RIGHT patient in the RIGHT side (or left lol)...😱
 
Before we operate I or my doc will mark the surgical site and we ask the patient which side they are having pain on, if it is on just one side.

Then we review the imaging.

I bring up the imaging in the room and verify the side and site for myself.

We have a timeout.

Before we cut we both look at the imaging and I will state we are operating on the right (or left) and the lesion is on the right (or left).

For spine operations we take intraop x-rays or fluoro and we both will count up or down (twice) to make sure we are at the right level.

Paranoid, obsessive-compulsive.

Yes, please. May I have some more?

I have special reason to be paranoid. When I was still a scrub tech I was involved in a partial wrong-site surgery. We were doing a nephrectomy and the surgeon made an incision on the wrong side and then realized his error. Thank god it did not go farther than that.

-Mike
 
We have a protocol for correct site marking before surgery where we have to verify the imaging and the concent for the correct site in the pre-op holding area. Recently there was some sort of wrong side foot surgery so they decided to revamp the whole thing. In a typical administrative nursing fashion they decided to go completely over board. I went in to preop a lap chole patient the other day and 2 nurses had already initialed and wrote yes on the patient's abdomen. They wanted me to be the third person to intial and sign the abdomen. We had purple marker grafetti all over the patient's belly. The patient did not speak English and I imagine she thought we were crazy. I refused to mark the patient a third time for a single organ surgery.
 
I went in to preop a lap chole patient the other day and 2 nurses had already initialed and wrote yes on the patient's abdomen. They wanted me to be the third person to intial and sign the abdomen. We had purple marker grafetti all over the patient's belly. The patient did not speak English and I imagine she thought we were crazy. I refused to mark the patient a third time for a single organ surgery.

I've had to mark a patient for:

(1) Splenectomy
(2) Hemorrhoids
(3) Penile fracture

🙄
 
I can see how this can happen in Neuro, without pre-op precautions. Been to a lot of these cases. The patient is many times proned/supined, trend/rev, rotated lt/rt, usually, totally unconscious. Once the patient is draped, I can't tell which sides the toes are on, and all before the attending gets there. These are of course emerg cases after trauma.

Likely, what happen with sen resident started on the R.I. case; emergent, at night, patient draped before attending arrived.

Need to be super, anal for surgery in general.

This kind of stuff will ruin your career. 😱
 
I've had to mark a patient for:

(1) Splenectomy
(2) Hemorrhoids
(3) Penile fracture

🙄

Um, this may be a bit personal but, how do you mark the surgical site for the penile fracture. Do you actually mark the member or is it another arrow thing.

It's just kinda creepy!

And I felt bad for marking the top of someones crack for an ESI 😀

-Mike
 
Um, this may be a bit personal but, how do you mark the surgical site for the penile fracture. Do you actually mark the member or is it another arrow thing.

I just drew a couple arrows below the umbilicus pointing to the base of the penis.
 
When I schedule cases, I must always indicate laterality or the program generates an error message. This automatically populates fields on the surgical consent, which is printed out with the packet.

I am really tired of explaining to people why their consent says "Bilateral infected pilonidal cyst excision" and "Bilateral C5-C6 laminectomy with fusion".

Wow...that's just weird. Good concept in theory, but poor practical approach.
 
Yeah, I hate it when the other people in the room just read the procedure off the consent, or off the chart - it makes it obvious they don't actually know what's wrong with the patient.

Like when they say, "ok, time out, this is Mr. Smith and today Dr. Jones is going to be performing a right partial thyroidectomy versus total thyroidectomy with possible partial parathyroidectomy versus total parathyroidectomy with possible sternocleidomastoid reimplantation."

So basically they have no idea what's going on. Reading through the progress notes, looking up the relevant labs/imaging - not important anymore?

I mean, we're all supposed to be members of the same surgical team. There are times the other people in the room don't even know the patient's diagnosis.
 
I know where you're coming from but circulators may not even be RNs, so I don't necessarily expect them to be knowledgable enough to know why certain procedures are done, nor to care.

You know the type...they don't answer your pages, they're never in the room when you need something, and they mispronounce the name of the surgery when reading it off the consent form.

I worry more when its a floor nurse taking care of my patient and she calls, not even knowing what surgery the patient had or why.
 
Really? Here all circulators are RNs. Weird...what would they be otherwise? LPNs?
 

Well that's weird.

The circulators here talk about how the OR and ICU are the coveted positions out of nursing school..."better ratios," they proclaim. 🙂

Now LPNs, I can see how they'd have some problems relaying messages over the phone when they answer your pages.
 
Well that's weird.

The circulators here talk about how the OR and ICU are the coveted positions out of nursing school..."better ratios," they proclaim. 🙂

Now LPNs, I can see how they'd have some problems relaying messages over the phone when they answer your pages.

Depends on where you are. In the west, especially in rural towns it is not uncommon to see LPNs in positions that you are used to seeing RNs in. It also depends on the state law. There are some areas that LPNs can't work in and some things that LPNs can do such as hanging blood. This is really state dependent. In the Army techs circulated and there was one RN per four rooms (that was a few years ago).

As far as ratios the numbers I see here are much better than out west (barring California). When I was a tech the Nurse😛T ratio was 1:8 or more. Haven't seen more than 1:6 here. Also just because the ratios are smaller doesn't mean you work less (ie. ICU).

David Carpenter, PA-C
 
Well that's weird.

The circulators here talk about how the OR and ICU are the coveted positions out of nursing school..."better ratios," they proclaim. 🙂

Now LPNs, I can see how they'd have some problems relaying messages over the phone when they answer your pages.


They ANSWER your pages?! What is this concept. Please explain.
:laugh:
 
i like it when they "stealth" turn it off...and don't answer it. then they say, "Oh, i didn't hear it go off." sure ya did, because you hit the buttons to stop the chirp!
 
Unfortunately, yeah. 🙁
Actually if you just put it in a pile with the attending's then they have to answer it. Our fellow showed me that trick.

David Carpenter, PA-C
 
i like it when they "stealth" turn it off...and don't answer it. then they say, "Oh, i didn't hear it go off." sure ya did, because you hit the buttons to stop the chirp!

I like it when they claim that they didn't hear it when they are 6 inches from the darn thing and the rest of us can!

Or when you ask if they answered the page and they'll claim they were busy and its only been 5 minutes since you were paged. Apparently they aren't aware that we can check when the page came in and show then that its been 25 minutes since the call.🙄
 
Also, on our pagers (Motorola Elite), each page has a blinking icon that stops blinking when you read the message. So we can tell when the circulator has pressed buttons already.
 
Actually if you just put it in a pile with the attending's then they have to answer it. Our fellow showed me that trick.

David Carpenter, PA-C

you're assuming that they answer the attending's! but good idea
 
I know of a program who operated on the wrong side for an acoustic neuroma...basically deafening the patient. Ver' bad. Our neuro-otologist now shaves the head on the correct side while the patient is awake. Hard to miss that, even when the patient gets turned around and draped in the OR.
 
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